Director Med Staff Services

Job Summary and Qualifications In this role, the Director of Medical Staff Services assists with the implementation of and compliance with credentialing initiatives and processes. The incumbent maintains a working knowledge of HCA Healthcare and Parallon Credentialing Processing Center policies, accreditation standards, and regulations associated with medical staff services and plays a key role in the integration of HCA Clinical Strategies and HCA systems. Qualifications include a bachelor’s degree in a related science or business field and at least five years of comprehensive experience in an acute care hospital or Credentialing Verification Organization, with a minimum of two years supervisory or management experience. Detailed knowledge of healthcare and credentialing law, regulatory standards, and experience with HCA Healthcare credentialing and Cactus is preferred. Certification in CPMSM and/or CPCS is required within the specified period. Benefits Comprehensive medical coverage that covers many common services at no cost or for a low copay, including prescription drug, behavioral health, free telemedicine, and free AirMed medical transportation. Additional options for dental, vision, life, disability, flexible spending accounts, supplemental health protection plans, auto and home insurance, identity theft protection, legal counseling, long‑term care coverage, moving assistance, pet insurance, and more. Free counseling services and resources for emotional, physical and financial well‑being. 401(k) Plan with a 100% match on 3% to 9% of pay. Employee Stock Purchase Plan with 10% off HCA Healthcare stock. Family support through fertility and family building benefits with Progyny and adoption assistance. Referral services for child, elder and pet care, home and auto repair, event planning, and more. Consumer discounts through Abenity and Consumer Discounts. Retirement readiness, rollover assistance services and preferred banking partnerships. Education assistance (tuition, student loan, certification support, dependent scholarships). Colleague recognition program. Time Away From Work Program (paid time off, paid family leave, short and long‑term disability coverage and leaves of absence). Employee Health Assistance Fund that offers free employee‑only coverage to full‑time and part‑time colleagues based on income. Medical Staff Administration Develop facility credentialing policies in accordance with accreditation and regulatory standards, HCA Healthcare policies, and medical staff bylaws. Facilitate meetings for the following committees: Medical Executive Committee Credentials Committee Leadership Council Other Medical Staff Committees, Departments, and Service Meetings as assigned. Coordinate work of the Leadership Council in matters related to practitioner health and professional conduct, and support functions for continued monitoring. Coordinate other facility committees as assigned. Maintain the official emergency call schedule and records for call compensation payments. Manage correspondence between facility and individual medical staff members. Provide support functions to medical staff officers in performance of their duties. Prepare credentialing reports for medical staff leaders, committees, and the governing body. Develop, maintain, and distribute medical staff governance documents (bylaws, rules & regulations, policies) and implement the annual review process. Serve as the primary liaison between the facility, Division Medical Staff Services, and the CPC. Ensure all facility non‑privileged practitioner processes follow the Ethics & Compliance Policy and electronic Security Access Form to trigger proper system access. Ensure tokens of appreciation and gifts provided to members of the medical staff are reported to the ECO for logging on the Business Courtesy Log. Coordinate collection and handling of medical staff dues and other fees in accordance with Ethics & Compliance Policy. Update Meditech Practitioner Dictionary/Database to be consistent with practitioner data in Cactus. Participate in planning for future medical staff recruitment. Develop annual business plan and supervise annual budget if assigned. Edit and write a medical staff newsletter or maintain the medical staff section of the facility website. Maintain and distribute master medical staff calendar of activities. Manage medical staff hotline. Medical Staff Education Facilitate orientation for new medical staff members in partnership with key stakeholders. Facilitate orientation for new officers, committee members and governing body. Provide education to administrators and department directors regarding CPC operations, MSSD operations, privileging, and non‑privileged practitioner credentialing. Facilitate any continuing medical education (CME) programs offered through the facility. Accreditation and Regulatory Compliance Serve as the facility’s subject matter expert regarding relevant accreditation and regulatory requirements related to the medical staff. Notify the CPC, Division MSS and corporate teams of any upcoming or ongoing surveys related to credentialing, privileging, and PPE/peer review activities. Coordinate accreditation, regulatory, and any internal surveys related to credentialing, privileging, and PPE/peer review activities. Respond to any reviews, accreditation and regulatory compliance citations or deficiencies by developing and implementing corrective action plans. Facility‑Based Credentialing Tasks Apply the credentials evaluation process uniformly to all RFC/applications and R‑RFC/re‑applications to ensure compliance with internal credentialing procedures. Process each RFC/application received from the CPC that has a flag in accordance with CPC‑32 and MSS‑002 policy. Verify applicant identity in accordance with MSS‑004. Forward any updated information received from a practitioner to the Division MSS/CPC in a timely manner. Compile and analyze internal data and information for an assessment of qualifications and competencies for each R‑RFC/re‑application. CME credits in accordance with medical staff bylaws. Volume. Focused or ongoing professional practice evaluations (FPPE/OPPE), performance improvement, utilization patterns, peer review, or other performance information. Facilitate review, assessment, and authenticated documentation of an evaluation of each application and request for clinical privileges by the section chief / department chairman as required. Facilitate review, assessment and recommendations for each application and request for clinical privileges by the Credentials Committee and the Medical Executive Committee. Utilize “paper‑lite” procedures to facilitate medical staff reviews/maximize use of iObserver functionality in Cactus. Summarize and prepare credentialing information, including information about flagged concerns, for the board’s review and decisions. Actively manage each practitioner’s expiring credentials in accordance with CPC‑36 and MSS‑003. Update Cactus and MEDITECH system’s Practitioner Dictionary/Database to reflect all board actions on a practitioner’s RFC, R‑RFC, including resignations, terminations, LOAs, denials, terminations, or withdrawals in accordance with CPC‑28 and MSS‑013. Manage and archive files according to HCA Healthcare and facility procedures and accreditation/regulatory standards. Privileging Facilitate development of eligibility criteria for each clinical privilege or grouping of clinical privileges that require the same qualifications and competencies. Facilitate the review of requests for clinical privileges using the approved eligibility criteria. Assess the applicability and appropriateness of clinical privileges for each specialty through periodic review. Maintain all up‑to‑date privilege content within the Visual Cactus system and MEDITECH Practitioner Dictionary/Database to reflect all board actions. Update electronic Security Access Form to trigger provisioning and/or deprovisioning of system access to align with practitioner’s membership status and/or clinical privileges. Coordinate access by authorized facility staff to credentialing information as needed through iPrivileges or iPharmacy portal. Facilitate any required regulatory agency reporting of adverse actions taken against a practitioner’s medical staff membership or clinical privileges, as directed by facility leaders. Performance Improvement / Peer Review / Patient Safety Coordinate with the facility’s quality department to facilitate focused professional practice evaluation (FPPE) and any related evaluation at the conclusion of FPPE or a period of provisional status. Coordinate with the facility’s quality department to facilitate ongoing professional practice evaluation (OPPE). Coordinate with facility leadership in the conduct of internal and external peer reviews. Complete a summary of FPPE, OPPE, and peer review results for evaluation by medical staff leaders as part of the R‑RFC process, and ongoing as required by policy. In collaboration with the CPC, identify critical MSSD performance benchmarks, measure performance, and take action to improve when performance is not as desired or expected. Coordinate with the facility’s Patient Safety Officer in the medical staff review of occurrence reports, patient complaints, close call data, and SPAE reports. Coordinate with the facility’s Patient Safety Officer regarding medical staff participation in any activities performed as part of the HCA Healthcare Patient Safety Organization, including appropriate handling of Patient Safety Work Product. Risk Management Coordinate with the risk manager to review and evaluate an applicant’s claims history and National Practitioner Data Bank or other reports regarding final settlements. Ensure timely and proper notification of the risk manager regarding possible malpractice or other liability concerns. Coordinate all medical staff disciplinary actions (e.g., formal investigations, professional review actions). Facilitate due process in accordance with the facility’s fair hearing and appeals policy as well as legal and regulatory requirements. In accordance with Ethics & Compliance Policy, submit a Reportable Issue report for any instance of a practitioner providing patient care within the facility without a legally required credential, or while under a Federal or state sanction, or without having current, approved clinical privileges. National Practitioner Data Bank (NPDB) Manage and maintain the NPDB account as the Data Bank Administrator. In collaboration with the facility’s Operations Counsel and appropriate facility leaders, submit reports to the NPDB as required by Federal law. Manage and respond to any requests for information made as a result of an NPDB report. Coordinate the completion of the NPDB’s Attestation by the facility’s Attesting Official at the time of renewal of the facility’s registration with NPDB. Subscribe to the “NPDB Insights” e‑newsletter; review it and communicate any changes in requirements to the appropriate facility executives. Information Management Develop and maintain a policy regarding the management, access to, and distribution of credentialing, privileging, and peer review information, in accordance with confidentiality requirements and record retention policies. Archive any locally maintained credentialing, privileging or peer review records in accordance with record retention policies. Respond to external requests for information in accordance with policy. HCA Healthcare System Coordination and Collaboration Attend initial orientation from the CPC and HCA Healthcare’s Office of Professional Practice Advancement. Maintain an acute awareness and accurate interpretation of the HCA Healthcare credentialing policies and procedures. Read and be familiar with HCA’s Model Medical Staff Governance Documents, the PPE Manuals, and other model medical staff policies, and support the facility’s medical staff in their review and adoption. Support facility adoption of template Medical Staff Services Department policies. Be familiar with CPC policies as they impact the facility’s MSSD. Read and act on announcements and alerts from the CPC: Expirable credentials notifications. Dynamic flag alerts. Notices of changes or updates to Cactus, or CPC procedures. Read and act on the weekly information from HCA Healthcare’s Office of Professional Practice Advancement (e.g., Answer of the Week, Important Updates, and other announcements). Participate in monthly “Village” calls. Attend and participate in scheduled Division meetings for MSPs. Ensure that facility Medical Staff Services operations conform to local, state, and federal governmental regulations as well as HCA Healthcare policy. Education Bachelor’s degree in medical staff services science, business, or related field of study or an equivalent combination of training and experience. Experience Minimum of 5 years comprehensive experience in an acute care hospital or Credentialing Verification Organization setting. Minimum of 2 years supervisory/management experience. Detailed working knowledge of the healthcare and credentialing industry, including medical‑legal issues and laws, regulatory standards as related to credentialing, privileging and peer review, and other regulatory and state standards. HCA Healthcare credentialing and Cactus experience preferred. Certification Certified Professional Medical Services Management (CPMSM) and/or Certified Provider Credentialing Specialist (CPCS) within the specified period of time as required by Division AVP MSS. Location and Salary Manchester, NH – Salary: $135,000.00 to $175,000.00. We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. #J-18808-Ljbffr HCA Healthcare